Hong Kong Physiotherapy Journal
Volume 30, Issue 1 , Pages 6-12, June 2012

Prevention of osteoporosis: From infancy through older adulthood

  • Donna Cech, PT, DHS, PCS

      Affiliations

    • Corresponding Author InformationMidwestern University, 555 31st Street, Downers Grove, IL 60515, USA.

College of Health Sciences, Physical Therapy Program, Midwestern University, Downers Grove, Illinois, USA

published online 20 February 2012.

Article Outline

Abstract 

Osteoporosis is a worldwide health concern for individuals of all ethnic and racial groups. The number of individuals diagnosed with osteoporosis and the rate of osteoporotic fractures increases significantly with age. Some variation in the development of osteoporosis can also be related to gender and race, with both genetic and lifestyle factors influencing bone development. Both non-modifiable and modifiable risk factors have been identified as contributing to the development of osteoporosis. Modifiable risk factors are related to diet, smoking, alcohol use and activity level. By understanding the development of the skeletal system and the lifestyle choices that maximize bone development, the risk of development of osteoporosis can be minimized. Physical activity contributes to development of the skeletal system in all age and ethnic groups. Maintaining high levels of physical activity is important across the life span to increase the peak bone mass developed and optimize bone mass during the bone remodelling phases of older adulthood. Bone development and remodelling are influenced by the mechanical strain placed upon the bone during physical activity. By understanding how mechanical forces influence bone development, exercise programmes can be developed that will most effectively stimulate bone growth. The focus of this review will be to discuss factors influencing the life span development of the skeletal system, theoretical frameworks related to bone growth in response to mechanical forces, and the development of osteoporosis prevention programmes for individuals of all ages.

Keywords: ageing, bone mineral density, children, exercise, osteoporosis

 

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Introduction 

Osteoporosis is a worldwide health concern for individuals of all ethnic and racial groups. As the world’s population ages, the incidence of osteoporotic fracture is predicted to increase, especially in populations outside the USA and Europe [1]. Projections have implied that more than 50% of the world’s osteoporotic hip fractures will occur in Asia by 2050 [2]. From a healthcare perspective, the economic impact of treating fractures occurring secondary to osteoporosis is significant [3]. Osteoporosis results in high personal and financial costs across the world, and for these reasons it is important to actively promote lifestyle behaviors that will help prevent osteoporosis.

Osteoporosis has been defined as a systemic disease characterized by a low bone mass and architectural changes within the bone tissue [4]. Bone mass refers to the amount of mineral in the bone tissue, while bone mineral density is a method of measuring bone mineral content. These terms are often used interchangeably. The architecture of the bone refers to the three-dimensional structural pattern of trabeculae and other structures in cancellous bone. Individuals are diagnosed with osteoporosis when their bone mineral density is more than 2.5 standard deviations below that of a reference range for young women [1], [5]. Although a variety of ethnic, gender and geographically based reference standards for bone density exist, it has been recommended that one universal reference standard should be used in order to diagnose osteoporosis more consistently across populations [6]. Low bone mineral density leaves the individual at risk of bone fracture, resulting in pain, participation restrictions and even mortality.

Inadequate accrual of bone during childhood and adolescence and/or excessive bone loss in adulthood both contribute to the development of osteoporosis [7]. Older adults, both men and women, are at risk of developing osteoporosis. In addition, those individuals with long-term physical disabilities, whose physical activity and weight-bearing experiences are limited, develop osteoporosis. Individuals with chronic disease of other body systems, such as the renal system, also develop secondary osteoporosis. The focus of this review will be limited to the life span development of the skeletal system and the prevention of primary osteoporosis in individuals who are developing typically and are not experiencing a chronic disease or long-term disability that will negatively impact on their skeletal system.

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Osteoporosis – types and patterns or occurrence 

The diagnosis of osteoporosis and the rate of osteoporotic fractures both increase significantly with age. Both non-modifiable and modifiable risk factors have been identified for the development of osteoporosis. Among the non-modifiable risk factors are age, small body size, family history, female sex, postmenopausal status, previous fracture and race. Generally, Caucasian race is considered to be a risk factor for osteoporosis, but Asian individuals appear to have a similar risk for the development of osteoporosis and osteoporotic fractures [8], [9]. Modifiable risk factors are related to diet, smoking, alcohol use and activity level. Dietary factors such as calcium intake, protein intake and vitamin D levels have been identified to influence bone mass and can play a protective role in the prevention of osteoporosis [10]. Hormonal levels of oestrogen, testosterone and growth hormone also influence bone development and are considered within the medical management of osteoporosis. Another key modifiable factor in bone development and osteoporosis prevention is physical activity, which contributes to both muscle strength and bone mass. Maintaining high levels of physical activity is important across the life span to increase peak bone mass developed and optimize bone mass during the bone remodelling phases of older adulthood.

In older adults, two categories of osteoporosis are seen. In the first category, bone mineral density decreases in both men and women, and is related to the impact of hormonal changes on the bone remodelling process [11]. Both testosterone and oestrogen influence the intestinal absorption of calcium from the bloodstream. As the intestinal absorption of calcium is decreased, stores of calcium in both cancellous and compact bone are retrieved to maintain necessary levels of serum calcium. Calcium is absorbed from the bone in greater quantities than can be replaced, and a decrease in bone mass is seen. The second category of osteoporosis is seen as women enter and experience menopause. The decreases in oestrogen level that occur with menopause are thought to increase the sensitivity of the bone to parathyroid hormone, increasing the rate of bone resorption and decreasing bone mass. The most rapid bone loss is seen during perimenopause, and then the rate slows, although it remains high during menopause [9]. For the 4–8 years after menopause, women lose significant amounts of cancellous bone through this process [12], [13], which contributes to the significantly higher percentage of osteoporotic fractures seen in women compared with men. The risk of fracture increases as the strength of the bone tissue is impacted by loss of bone mass and changes in bone structure/architecture.

The most frequent sites for atraumatic, spontaneous fracture in individuals with osteoporosis are the spine, proximal femur and wrist, which contain a high proportion of cancellous bone. During perimenopause, decreases in bone mineral density have been noted in the spine, but as women move into the postmenopausal period, changes in bone mineral density are seen in the spine, femur and hip [9]. Some variation in the frequency of osteoporotic hip and spine fractures is seen in Caucasian and Asian populations. The incidence of both hip and spine fractures increases with age, but Asian populations experience a lower rate of hip fractures than Caucasian populations. Asian women, however, have a higher rate of vertebral fracture than Caucasian women. In Southern China, the incidence of hip fractures is reported to increase in men from 10/1000,000 person-years at age 50-54 years to 477/100,000 person years at age 85 years and above. For women the incidence increases from 16/1000,000 person-years to 1377/1000,000 person-years. Similarly, in this population vertebral fractures increase from 50/100,000 person-years in men, ages 50-54 years to 954/100,000 person-years at age 85 years and above. In women in Southern China, vertebral fractures increase from 219/100,000 person-years at 50-54 years of age to 2689/100,000 person-years at age 85 years and above [8].

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Understanding bone growth and remodelling across the life span 

Bone growth and development across the life span is influenced by both heredity and environmental influences. The general form and relationship of components of the skeletal system are genetically determined. Bone mass, thickness, shape and internal architecture are influenced by environmental factors such as diet and the mechanical stresses placed upon the bone tissue. Ethnicity has been shown to influence bone development and bone mass. Dietary factors, lean body mass and levels of physical activity contribute to the ethnic variations seen. Asian and Hispanic children have been shown to have a lower bone mass than their Caucasian peers, whereas black children have a higher bone mass [14], [15]. In Asian populations, children’s calcium intake and vitamin D levels are lower than in Caucasian populations [15], [16]. In adults, bone mineral density has also been reported to be lower in Asian populations than in Caucasian, black and Hispanic populations [6]. Smoking, diet (especially calcium intake), activity level and socioeconomic status have been found to influence bone mineral density.

Through childhood and adolescence, bone growth occurs by the endochondral ossification of new bone produced at the epiphyseal and apophyseal growth plates of the developing bone, contributing to the length and shape of the mature bone. Throughout the life span, appositional bone growth occurs through the activity of osteoblast and osteoclast cells, contributing to the thickness of the bone collar and the internal architecture of the bone. Osteoblast cells form new bone cells on the periosteal surface of the bone and in the trabeculae. Osteoclast cells stimulate bone resorption from trabeculae and the endosteal surface of the bone. In childhood and adolescence, bone formation exceeds bone resorption and bone mass increases. In older adulthood, bone resorption exceeds formation, resulting in a loss of bone mass. Both weight-bearing forces and muscle pull on the bone provide the stimulus for endochondral and appositional bone growth.

Several theoretical models contribute to understanding the influences of mechanical loading on bone development. A few of these theories, which contribute to the rationale for including specific types of physical activity in osteoporosis prevention programmes, will be discussed. Wolff’s law of bone transformation [17] states that bone will change in response to the mechanical load placed on it. Both weight-bearing and the pull of muscle attachments on the bone contribute to bone remodelling and the formation of an internal bony architecture that can withstand the forces placed upon the bone. The mechanostat theory also states that strain is required for adaptation of bone, in order to develop an effective load-bearing skeletal system [18], [19]. In this model, loading frequency and the magnitude of the strain are important in stimulating the adaptation of the bone. As mechanical forces (i.e. the pull of muscle contraction) are placed upon the bone, the osteocyte detects the strain and triggers osteoblast activity to form new bone. If the osteocyte does not experience mechanical loading, osteoclast activation results in bone resorption [20]. A third theory, cellular accommodation theory, expands the explanation of bone response to loading by identifying that the strain threshold for signalling bone adaptation is plastic and responds to variation in the loading forces placed upon the bone [21], [22]. Initial peak strain threshold is important in determining amount of bone adaptation that occurs, but, over time, the bone stops adapting to the load. This theory implies that because bone accommodates to routine strains, changes in mechanical loading are necessary to optimize bone development [21]. Fig. 1 reflects the key aspects of both the mechanostat theory and the cellular accommodation theory on bone growth and development [23].

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Prevention – role of nutrition and physical activity 

Prevention of osteoporosis is a worldwide focus because of the high personal and financial cost of the disease. For prevention efforts to be most successful, the general population must have knowledge about the disease and the best ways to maximize their bone health across the life span. Osteoporosis prevention focuses on making lifestyle choices that address the modifiable risk factors for osteoporosis. In a recent study of college students in the USA and China, both groups of students had inadequate knowledge about osteoporosis as a disease, the severity of the disease and their likelihood of developing osteoporosis. Students in the USA had stronger beliefs about the role of exercise and calcium intake in prevention of osteoporosis than did college students in China [24]. As preventive efforts during college age can impact on bone health in older adulthood, this study provides an example of the importance of education to all age groups of the general population. In another study of adult Chinese immigrants living in the USA, an educational programme focusing on increasing knowledge of osteoporosis and preventive strategies was shown to increase individuals’ knowledge about osteoporosis and their adoption of prevention behaviors such as participation in exercise programmes and compliance with the use of medication [25].

From a life span perspective, it appears that attaining the greatest peak bone mass possible contributes to delaying the onset of osteoporosis in older adulthood and to the risk of osteoporotic fracture [26], [27], [28]. Even maternal lifestyle choices during pregnancy (such as smoking, vitamin D intake and calcium intake) appear to have an impact on bone mineral content of the child [3]. Lifestyle choices related to diet, nutrition, smoking, alcohol use and level of regular physical activity have been suggested to help prevent osteoporosis. A cross-sectional study of Korean adults showed that men who exercised two or three times a week were less likely to develop osteoporosis than men who did not exercise [6]. In older adults, increasing levels of physical activity have been effective in improving bone mass [26], [29], [30], [31].

With respect to diet and nutrition, recommendations include maintaining adequate levels of calcium and vitamin D, maintaining a healthy body weight and eating a well-balanced diet with adequate protein, fruit and vegetables. Calcium and vitamin D are both important for bone formation and maintenance [32], [33]. Dietary calcium can come from dairy products and other sources such as dark green vegetables. Even though the calcium in dairy products is more easily absorbed from the intestine, vegetable sources of calcium (when eaten in sufficient quantity) can also contribute to improving bone mineral density and decreasing the risk of osteoporosis [34]. Other vitamins and minerals, many of which are found in fruit and vegetables, support good bone health. Protein also plays a role in the development [33] and maintenance of bone mass. Consumption of fish, especially sea fish, has been linked with the maintenance of bone mineral density in older adults living in China [10].

Other dietary and lifestyle choices have been reported to be detrimental to bone health and should be minimized. For example, smoking [35], [36] and alcohol consumption [37], [38] are recognized risk factors for osteoporotic fracture among older adults. Carbonated beverage and caffeine consumption have also been identified as increasing risk of osteoporotic fractures. With regard to caffeine consumption, tea consumption does not seem to have the negative impact on bone health that coffee and cola do, and in fact tea may even improve bone mineral density by supporting osteoblast activity [39], [40].

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Maximizing bone health and growth through physical activity 

Participation in physical activity and exercise is recommended for the prevention and treatment of osteoporosis. Both weight-bearing exercise and muscle contraction place a mechanical load on bone tissue and have beneficial effects on bone health, with a decreased risk of fracture [41]. Physical activity has been demonstrated to increase bone mineral density in children and adolescents [27], [42], [43], [44], [45], [46]. Children attain 50–60% of their peak bone mass by puberty and up to 90% (boys) to 95% (girls) by age 20 [27], [47]. In adolescence, especially the 2 or 3 years surrounding peak height velocity, bone mass increases more than at any other time of life [27], [33], [43], [48]. Individuals who are physically active as children and adolescents have a greater bone mass through adulthood than their peers who are inactive as children. In Asian adolescents, physical activity and lean body mass have been shown to contribute to bone growth [7], [49]. Weight-bearing and resistive exercise programmes stimulate appositional bone growth in adulthood, especially when high-impact activities are included [29], [50], [51], [52], [53], [54]. In older adults, loss of bone mass will occur, but maintaining physical activity levels (including weight-bearing and strength training components) can help to minimize the decrease in bone mineral density [29], [51], [53], [54], [55], [56]. Older adults who live in rural areas and may therefore have more active lifestyles have a later onset of osteoporosis and less severe osteoporotic fractures than those who live in metropolitan areas [57].

Because physical activity plays a key role in bone development across the life span, physiotherapists can make a valuable contribution to the development of prevention programmes and public education related to osteoporosis. Regardless of age, ethnicity or gender, the recommendations include participation in regular physical activity. It is important to consider factors influencing bone growth, age-appropriate physical activity and mechanisms to maximize bone mass at each individual stage of the life span.

Infancy 

Infancy is a time of bone growth. The diaphyses of the long bones are ossified at birth. Secondary ossification centers (epiphyses) develop from infancy through adolescence, with genetics, nutrition and overall health contributing to a determination of when the epiphyses will appear. Based upon the weight-bearing and muscular stresses placed upon them, bones grow in length and thickness, as well as changing in shape, angulation and rotation. Movement against gravity also contributes to muscle strengthening, and the stronger muscles exert a greater pull upon the bone during physical activity.

Infants should be encouraged to play and move in a variety of weight-bearing positions such as prone, sitting, four-point, kneeling and standing. As the infant assumes more upright positions against gravity and transitions from one position to another, muscle strength develops. Skeletal alignment also accommodates to provide an efficient framework and support system during movement (i.e. by the development of the spinal curve and femoral torsional changes).

Childhood 

The rapid growth of the skeletal system continues through childhood, with periods of rapid growth from 1 to 4 years of age and again at puberty [27]. Participation in physical activity will result in the growth of both muscle and bone mass. During this time period, participation in high-impact activities such as jumping, soccer and other sports has been found to stimulate increased site-specific bone mineral density [42], [58], [59] and bone growth [45]. Because the epiphysis is an active site of new bone formation during childhood, forces acting on the epiphysis can impact on bone growth. Fractures of the epiphyseal plate occur because the growth plate is not as strong as the surrounding bone. Children are especially susceptible to growth plate fractures as they enter the period of peak height velocity growth [60]. Injury to or infection of the epiphysis can cause abnormal growth of the bone [61].

Children should maintain high levels of physical activity through childhood to maximize bone mass during this growth period, especially considering that they will attain 50–60% of their peak bone mass by puberty. Especially in the years preceding peak height velocity, high-impact activities such as jumping and playing soccer should be encouraged [44], [45].

Adolescence 

Adolescence is a time during which bone mass rapidly increases. Physical activity, the maintenance of a healthy body weight, and calcium intake contribute to bone growth, formation of bone matrix and bone mineralization [7], [15], [27], [45], [49], [62], [63], [64]. During the peripubertal and pubertal periods, the appearance of increased levels of oestrogen and androgens signals for the adolescent growth spurt, support bone acquisition and stimulate bone mineral metabolism. Other hormones such as growth hormone, thyroid hormone and parathyroid hormone also contribute to bone growth, increasing bone mass and regulating bone metabolism during puberty. Vitamin D plays a role in promoting bone mineralization and increasing muscle strength [33]. Bone growth in length generally precedes growth in muscle length, limiting flexibility in adolescents and increasing risk of injury.

Exercise during the prepubertal and early pubertal years has a greater impact on stimulating bone growth than exercise in the post-pubertal years. Activities such as running and jumping, and sports such as basketball and soccer, are recommended to stimulate the maximum growth and adaptation of the bone. These activities vary in terms of the magnitude and rate of mechanical strain placed upon the bone and thus maximize bone adaptation [65].

Adulthood 

Through adulthood, appositional bone growth and bone remodelling continue. Men and women acquire their peak bone mass by their early 30s. Bone formation and resorption continue at similar rates until 30–50 years of age in men and 38–48 years of in women, with the range of ages related to ethnic variation [66]. After this time, bone loss begins to exceed bone formation, beginning in cancellous bone in the third decade of life and in cortical bone in the fourth decade [11], [13].

Weight-bearing and strength training exercise stimulates appositional bone growth in adults. The exercise also increases muscle mass, allowing muscle to place a greater force on the bone. High-impact activities, such as jumping, tennis, volleyball and basketball, should be included to maximize appositional bone growth [29], [50], [51].

Older adulthood 

Loss of bone mass continues through older adulthood, as bone resorption continues to exceed bone deposition. Decreased oestrogen levels in older adults contribute to loss of bone mass. Decreased levels of oestrogen and testosterone also influence the ability of the intestine to absorb calcium, which triggers a depletion of bony calcium stores [11].

Weight-bearing exercise and strength training continue to be effective in older adults for maintaining bone health [29], [51], [67]. Exercise also improves strength, posture and balance, which contribute to improved function and the prevention of falls [68]. Power training, which includes both resistance and speed components, appears to be the most effective in maintaining bone mass in older adults [69]. A variety of weight-bearing activities, such as walking, jogging, tai chi, dancing and stair-climbing, are important because they all place changing stresses on the bone. Increasing the pace of walking has been found to be more helpful than increasing the amount of time walked because increasing the walking pace increases the forces generated at the hip [41]. Combined exercise programmes of weight training and weight-bearing, dynamic activities appear to best increase bone mass at both the femur and the spine [53], [54].

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Summary 

Osteoporosis is a systemic disease characterized by loss of bone mass and architectural changes in bone tissue. As the world population ages, the incidence of osteoporosis is expected to increase, resulting in high personal and economic costs. Because of the dynamic nature of the skeletal system, lifestyle choices (diet, nutrition and physical activity) influence the growth, development and maintenance of bone tissue, making osteoporosis prevention an important focus in healthcare. It is important to begin prevention early in the life span, taking advantage of the ability to maximize peak bone mass in children and adolescents.

A lifetime commitment to good nutrition and physical activity is important for the development and maintenance of a healthy skeletal system. Osteoporosis prevention strategies for individuals of all ages and all ethnic groups include:

•eating a well-balanced diet to supply the vitamins and minerals required for bone maintenance, and to provide an energy source to support growth and function;

•ensuring a sufficient intake of calcium to support bone growth and mineralization;

•participating in regular physical activities and exercise three to five times a week for 10–45 minutes per session to increase muscle strength, flexibility and coordination; activities should include diverse movement activities and patterns of mechanical strain to stimulate bone growth throughout the skeleton, with moderate-to-high impact activities for children and adolescents, and low-to-moderate impact activities for middle-aged and older adults.

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PII: S1013-7025(12)00003-6

doi:10.1016/j.hkpj.2012.01.002

Hong Kong Physiotherapy Journal
Volume 30, Issue 1 , Pages 6-12, June 2012

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